Radial versus femoral approach in STEMI: what do we know so far?

Radial approach has been used since 1989 to perform coronary angiography as an alternative to femoral access. During past decades, the development of dedicated equipment has led to high efficacy also in complex procedures. ST elevation myocardial infarction (STEMI) is known to be a high bleeding risk setting and in turn bleeding events can negatively impact on outcomes. Observational studies have demonstrated feasibility, efficacy and safety of radial approach when compared to femoral access in STEMI patients, with benefit in bleeding rates. These advantages have also been described in specific populations such as in the elderly and in patients with cardiogenic shock. Some large randomized trials have been conducted to assess outcomes of transradial access versus transfemoral access, with RIVAL and MATRIX representing the largest two studies. The RIVAL documented a significant reduction in access site-related complications in the global population of acute coronary syndrome (ACS) patients, with also lower mortality and net clinical adverse events (NACE), mainly driven by significant reduction of bleeding and all-cause mortality, in the STEMI sub-group. Overall, the MATRIX trial confirmed that radial access decreased bleeding and all-cause death thus reducing the rate of NACE and supporting the transradial access as the one to be preferred in ACS patients. Clinical advantages of radial access have been also tested in smaller randomized trials corroborating the evidence of radial access as a highly recommendable alternative to femoral access in the setting of primary percutaneous coronary intervention (p-PCI). The current evidence suggests that radial access should become the default access for patients with ACS undergoing invasive management.